14 HIV Intro/Drugs Mak Flashcards
What is the recommendation for initiating ART when looking at the CD4 count?
CD4 count < 350. Debatable when > 350
What is the recommendation for initiating ART regardless of CD4 count?
Pregnancy. History of AIDS-defining illness. HIV-associated nephropathy (HIVAN). Hepatitis B (HBV) coinfection. Age > 50 years
What happens with AIDS defining illnesses?
A patient with HIV and one of these illness automatically gets classified as having AIDS, regardless of CD4 count. Once in AIDS category, always in it, even if AIDS defining illness resolves
What are the general characteristics of CD4 count?
Major indicator of immune function. Assess trend and most recent CD4 count. A key factor in decision to start ART or OI prophylaxis. Important in determining response to ART (adequate response: CD4 increase 50-150 cells/uL per year)
When is CD4 monitoring done?
Check at baseline x2 and at least every 3-6 months
At what CD4 count is OI prophylaxis needed?
< 200
What are the general characteristics of VL?
VL influences decision to start ART and help determine frequency of CD4 monitoring. Critical in determining response to ART (Goal of ART: HIV RNA below limit of detection)
When is RNA (VL) monitoring done?
Check at baseline (x2); immediately before initiating ART. 2-4 weeks (no more than 8) after start or change of ART, then every 4-8 weeks until suppressed to < 200 copies/mL. Every 3-4 months if stable. Isolated “blips” may occur (typically < 400 copies/mL)
What happens when considering a deferral of ART?
Clinical or personal factors may support deferral (if CD4 count is low, deferral considered only in unusual situations, and with close follow-up). Significant barriers to adherence. Comorbidities complicate or prohibit ART. “Elite controllers” and long-term nonprogressors
What are the goals of ART therapy?
Improve quality of life. Reduce HIV-related morbidity and mortality. Restore a/o preserve immunologic function. Maximally, durably suppress HIV viral load. Prevent HIV transmission
What are the pretreatment evaluations for HIV?
HIV status (VL, CD4). CBC, CMP, UA, STDs, Hepatitis, Lipids. Opportunistic infections. PAP smear, prostate exam. Resistance testing. If indicated, or positive for risk factors: Psychiatric illness, substance abuse, comorbidities, economic and social support, adherence levels
What is done in resistance testing?
Genotype (detect drug resistance mutations that are present in the relevant viral genes). Phenotype (measure a virus’ ability to grow in various concentrations of ARVs, similar to bacterial C&S tests (shows IC50), compare with reference viruses (report fold increase cutoffs))
What is Drug Resistance Testing recommended?
Acute HIV infection, regardless of whether treatment is to be started. Chronic HIV infection, at entry into care. Pregnancy
What is HLA-B*5701 screening for?
Before starting Abacovir (ABC), to reduce risk of hypersensitivity reaction (HSR). Highest incidence in Caucasians and African Americans
What is a Coreceptor Tropism Assay for?
Performed when considering a CCR5 antagonist. Requires plasma HIV RNA >1,000 copies/mL. Consider in patients with virologic failure on a CCR5 antagonist (though does not rule out resistance to CCR5 antagonist)
What are the general characteristics of NRTIs?
All NRTIs need to be converted intracellularly to active triphosphorylated forms. MOA: inhibit transcription of vRNA into sdDNA. Not involved as P450 inducers or inhibitors. Renally eliminated. Little cross-resistance among NRTIs
What is toxicity usually like with NRTIs?
Mostly attributed to mitochondrial toxicity: Lactic Acidosis and Hepatomegaly with Steatosis are BBWs
What is Zidovudine (Retrovir)?
AZT, ZDV. NRTI. Durability about 12-24 months. Usually Co-Rx with 3TC (Combivir) and with 3TC/ABC (Trizivir)
What is Zidovudines undisputed efficacy in?
Preventing perinatal transmission. As postexposure prophylaxis. CSF penetration, higher dose needed for HIV associated dementia
What is the dosage like for Zidovudine?
300mg BID. Dosage reduced only in severe renal impairment
What are the ADRs associated with Zidovudine?
> 6-8 weeks: Hematologic toxicities: neutropenia and anemia. Lactic acidosis and Hepatomegaly with steatosis. Myopathy (increased CPK). Macrocytosis, hepatitis and hyperpigmentation of nails and skin (may indicate adherence). 1st month: N/V/A, HA, malaise, insomnia, confusion, flu symptoms
What is Didanosine (Videx EC)?
ddI. NRTI. Higher IC50 than ZDV (lower penetration into CSF than AZT, better activity vs. AZT in monocytes and macrophages). Acid labile, food limit absorption by 50%. Adjust dose based on weight and renal function
How is Didanosine dosed?
250-400mg QD
What is a DDI with Didanosine?
Concentration increased by TDF, but early virologic failure d/t resistance